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Supervision in Primary Care

Posted By Elizabeth Zeidler Schreiter, Meghan Fondow, Monday, March 16, 2015

This is the second in a two-part series on supervision in integrated care. Click here for the first post.

With the increased awareness of the benefits of integrating behavioral health care within the primary care setting there is an ever increasing demand to ensure we have behavioral health providers that are trained not only to provide care within this setting, but also to thrive alongside their primary care colleagues and function well as part of an interdisciplinary team.  Given the pace and intensity of the work in primary care, supervision is an essential tool to foster growth in trainees and to monitor progress.  At Access Community Health Centers we strive to provide excellent patient care as well foster the professional development of future psychologists and social workers as Behavioral Health Consultants (BHCs) within the Primary Care Behavioral Health model.



We work with trainees according to their level of development, as we have taken on a broad spectrum of trainees from various training programs including practicum level students from clinical psychology, counseling psychology, rehabilitation psychology, MFT programs, and social work programs over the past 9 years.  In addition, we have 2 post-doctoral fellowship positions annually for PhD/PsyD level trainees.  

Training of Clinical Skills

In many ways, our style of supervision mirrors the medical preceptor model of supervision, with live, in the moment supervision occurring throughout the day.  This enables supervisors to discuss each individual patient and their unique needs in real time.  Live shadowing, where the supervisor is present for all or part of a visit, allows for more in depth and robust feedback.  Although trainees often find shadowing to be anxiety provoking initially, it can also facilitate a more efficient visit as supervisors can speak to specific questions from the trainee regarding resources or options for care directly with the patient.  Co-visits are be possible for particularly complex cases or issues a trainee may feel they have less knowledge or comfort in addressing.  As we are keenly aware, providing care within the primary care setting requires a generalist mindset with the ability to show humility and openness for continual learning.

Our typical training scenario is as follows: 

  • Trainees begin by shadowing a BHC, to observe the entire process from obtaining a warm-handoff, interacting with other providers, seeing the patient in the exam room to conduct the BHC visit, following up with the provider and documenting the visit. 
  • Trainees shadow Primary Care Providers (PCP) to gain insight into the pace and breadth of the work in addition to the culture of primary care. 
  • Once students are comfortable in the primary care setting and can effectively introduce BHC services, they begin to see patients on their own. 
  • Supervisors continue to spend time with trainees in pre-visit planning, clarifying the consultation question, and helping trainees to organize their agenda for the visit once they begin the process of working more independently. 
  • There is also much discussion on staying flexible to meet the needs of the patient in the room as well as addressing PCPs expectations for the visit. 
  • Supervisors attempt to shadow as many consults as the schedule allows each day.  However, if we are unable to shadow, then trainees will review their thoughts with their supervisor after the visit, focusing on patient functioning, plan of care (interventions), and process issues. 
  • Since we utilize SOAP notes for documentation we typically have trainees present to us their overall assessment and plan to assist with case conceptualization and organization of their thoughts prior to seeking out the PCP to share their impressions. This builds trainee confidence and encourages succinct communication when interfacing with PCPs.
  • We coach trainees on focusing on one or two things to work on with patients during a visit which requires the trainee to assess and triage needs, prioritize options, and engage in shared decision making with the patient regarding areas of focus.


Training as Consultant

Supervision is always multifaceted while supporting the professional growth of trainees in various stages of development. Accordingly, this extends beyond the development of direct patient care skills. We strive to acculturate trainees to the primary care mentality of efficiency, compassion, and targeted interventions while also modeling self-care and seeking out support and feedback from other members of the healthcare team. Trainees and BHC staff use the same work areas as PCPs, sitting side by side with our primary care colleagues fostering a reciprocal learning environment.  This allows students to gain appreciation for the variety of responsibilities handled by PCPs and other care team members.  

Given that the PCP is our first customer, it is crucial to model and support professional development of the trainee as a consultant including the way a trainee presents him or herself to our primary care colleagues. Fostering self-awareness and professionalism while understanding the importance of balancing the relationship with the patient and the PCP is highly valuable and one way to encourage acculturation into primary care.  Relationship building is the cornerstone of work as a BHC.  Supervisors emphasize modeling collaborative and assertive communication with PCPs as an additional feature of the consultant role.

Supervisors model collaborative and assertive communication with physicians 


Similarly to focusing on one or two issues with patients, we as supervisors have found that trainees also benefit from focusing on only a few pieces of feedback at a time.  It can easily be overwhelming for trainees to hear all the options of what “could have” been discussed in each visit or interaction with PCP, as it is easy to mistake options for errors.  Helping students to learn that there are many ways to provide care and identify their own style is also important. 

At Access, staff supervisors rotate between three clinics. While each trainee has a primary supervisor they also have the opportunity to work with several staff members and supervisors increasing their exposure to a variety of practice habits and clinical orientations.  This experience fosters identity development and allows supervisors to share feedback and comments on areas of strength and areas for further development.

Overall, supervision in primary care works well when it reflects the pace and culture of the setting- immediate feedback, diversity in feedback across supervisors, and ongoing support throughout the workday.  Attending to development of both roles, clinician and consultant will allow for the most growth for the trainee and assist in preparing a future workforce ready to take on the role of a BHC.  


Elizabeth Zeidler Schreiter, Psy.D., is a licensed psychologist working at Access Community Health Centers (Access) in Madison, WI, providing primary care behavioral health services. In addition to direct patient care and supervision of trainees she serves as the liaison to the community and manages the consulting psychiatry service including training of psychiatry residents to practice within integrated care teams. She received her Psy.D. in Clinical Psychology from The School of Professional Psychology at Forest Institute with an emphasis in Integrated Health Care. In addition, she holds an appointment as a Clinical Assistant Professor with the UW Department of Family Medicine, where she assists with the training of family medicine residents. Dr. Zeidler Schreiter is passionate about working with the underserved and improving access to care via the primary care behavioral health model in addition to training new behavioral health consultants.


Meghan Fondow, Ph.D. is a licensed clinical psychologist working at Access Community Health Centers (Access) in Madison, WI, working as a behavioral health consultant (BHC) within the Primary Care Behavioral Health (PCBH) model. In addition to providing direct patient care, she is the Clinical Training Director, and tracks quality improvement data. She also holds an Adjunct Assistant Clinical Professor position through the University of Wisconsin-Madison Department of Family Medicine. Dr. Fondow received her PhD from The Ohio State University in Clinical Health Psychology. Dr. Fondow enjoys the variety and diversity of clinical work within the PCBH model in the context of an underserved population, working students and fellows with a variety of training backgrounds within the PCBH model, and practice based research.

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